Transcript Acute Abdomen

Dr. Nishan Silva
(MBBS)
defined as any clinical condition characterized
by severe abdominal pain which develops
over a period of 8 hrs.
In pt who have been
previously well.
rapid and accurate diagnosis is essential for
morbidity and mortality process.
Visceral pain; due to stimulation of visceral
afferent nerve plexus usually in midline result
from contraction or distension against
resistance & chemical irritation usually colicky
in nature.
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Parietal pain; 2dry to partial peritoneum
irritation perceived through segmental
somatic fibers reflex involuntary muscle wall
rigidity may result from irritation of
segmental sensory nerves.
Hyperesthesia of the skin may be result from
ipsilateral peritoneal irritation usually a sharp
ache.
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Gastrointestinal tract*
Acute appendicitis
Meckl”s diverticulitis
bowelPerforated
ulcer
Perforated peptic
obstruction
Small and large bowel
herniaStrangulated
Diverticulitis
Gastritis
Gastroenteritis
Inflammatory bowel disease
lymphadinitis Mesenteric
spleen. and , liverBiliaryTract
sCholangiti acute
Cholecystitis acute
Hepatic abscess
tumor
Ruptured hepatic
spleen
Ruptured
biliary colic
, Hepatitis acute
infarct Splenic
Peritoneum
Intra-abdominal abscess*
Primary peritonitis
Tuberculosis peritonitis
Pancreas
Pancreatitis, acute
ca pancreases
Urinary Tract
Cystitis acute
Pyelonephritis acute
Renal infarct
teral colicUre
Gynecological ;
ruptured ectopic pregnancy
Ruptured ovarian follicular cyst
Twisted ovarian tumor
Dysmenorrheal
Endometriosis
acute salpingitis.
PIDs
Male reproductive tract.
 Prostatitis
 Cystitis
 Torsion of testes
 Vascular causes
Acute ischemic colitis .
Mesenteric thrombosis*
Ruptured arterial aneurysm*
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Pneumonia.
Myocardial infarction
Sickle cell crisis.
DKA
Leukemia
Herpes zoster
psychogenic
History.
1. pain
2. Associated symptoms, nausea, vomiting,
Change of bowel habitués, jaundice, anorexia,
Heamatemsis, melena, dyspepsia
3.Menstruatin & sexual history.
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4.ROS
5.past medical & surgical hx
6.hx /o medications
7.familay Hx
8.social Hx
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1.general appearance,
Vital signs.
3.abdomial exam
4.rectal exam
5.pelvic exam (female pt)
2.
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1.CBCs,
WBCs & differential.
RBC & hct, degree of anemia & hemocon.
Platelet count, evidence of cougalopathy.
2.electrolyte,
(G, Na, K, Cl, Ca ,Mg, Po)
Indicative of volume status, GIT loss,
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3.ABG,
Indicate metabolic acidosis or alklosis.
M.acidosis with generalized abdominal pain
in elderly is ischemic colitis till proven other
wise.
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4.liver function test
Bilirubin (D or ID), ALP elevation in biliary
obstruction & transaminase elevation in case
of hepatocellular injury.
5.RFT
Urea, creatinin elevation in renal insufficiency
Serum albumin decrease in edema / ascitis.
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6. serum amylase
Seen in pancreatitis although non specific
may be elevated in mesenteric ischemia,
perforated peptic ulcer, rupture ovarian cyst
& renal failure. But lipase more sensitive.
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7.serum B_HCG
Mandatory for all women in childbearing
period.
8.urinalysis
See WBC RBC & casts.
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1.CXR,
Look for pneumonia, free gases under
diaphragm .pleural effusion suggest sub
diaphragmatic inflammatory process.
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2.abdominal Xray.
(Erect & supine position )
* bowel distension & air fluid level
*bowel gas cut off vs air through rectum.
*sentinel loop vs pancreatitis
*abn calcification vs ch.pancreatitis,stone
*pnumatosis vs omnious sign of dead gut.
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3.ultrasound,
*hepatobiliray tree(stones,mass,thickining of
the wall)
*pancreases
*kidney
*pelvic organ
*intrabdominal fluid collection
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4.CT_scan
Helpful in case of abdominal pain without
clear etiology better in evaluation of
abdominal oartic aneurysm.
5.helical CT_scan
Provide rapid cost effictive dignostic tool.
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5.contrast study
A. barium study
*perforation,
*discering point of obstruction in small
bowel.
*avoid if colonic diverticuilitis is suspected
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B_ intravenous pyelogram
For dignosis of ureteral stone or obstuction
C_angiography
For mesenteric ischemia
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6.endoscopy,
EGE, for evaluation epigastric pain in non
acute setting.& git bleeding
Sigmoid\colonoscopy
*colonic obstruction
*dig IBD,ischimic colitis lower bleeding,
*nonstrangulated sigmidal volvulus
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7.paracentesis &\or peritoneal lavage
*spontaneous bacterial peritonitis in cirrhotic
pt
*peritoneal lavage may be useful bedside test
in diagnosis of mesenteric infarction in
critically ill pt.
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8.culdocentesis
Valuable in diagnosis of rupture ectopic
pregnancy.
9.laproscopy
*D & ttt of suspected gynec.cause
*appendectomy if appendicitis is found in a
women in childbearing period.
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*promote timely work up in first 4_6hrs.
*keep pt Npo till the diagnosis is firm & ttt
plan is formulated.
*IV fluid. based in expected fluid loss.
*heamodynamic monitoring.
*NGT bleeding ,vomiting ,sign of obstruction
or when urgent laparoscopy is planned in pt
not NPo.
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Foley catheter to monitor fluid out put
decisions
Immediate surgery
* what is the timing of operative intervention(
does pt need time for resuscitation)
*what incision should be used?
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* what are the likely findings?
*develop primary operative plan.
* consider alternative diagnosis & plan.
* use appropriate pre-operative antibiotic
based on suspected pathology.
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2. admit & observe for possible operation.
*serial examination every 2-4 hrs during the
first 12-24 hrs in case without definite
diagnosis; minimal use of narcotics &
sedatives to avoid masking physical sign &
symptoms.
*monitor vital signs frequently
*serial lab exam may be useful ;repeat CBC
every 4-6hrs.
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3.no operation develop ttt plan for further
diagnostic workup or non operative therapy.
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Pain, vomiting and fever in order is the
classical triad of symptoms
Typical symptoms if present indicates that
the inflammation is advanced
Atypical symptoms like diarrhoea occur in
children and in pelvic appendix
inflammation
Initial pain is vague producing sense of
downward urge.
Vomiting occurs early about 3-4hrs after
onset of pain.
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Degree and frequency of vomiting is related
to the degree of appendicular distension
Vomiting before pain is extremely rare in
appendicitis and almost excludes it.
Local tenderness – elicited by light
percussion is a remarkably reliable
indication of parietal peritoneal
inflammation
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Hyperesthesia confined to areas of
T10,11,12,L1 distribution
Rigidity – frequent but not constant
No rigidity in appendicitis without peritonitis
Fever develops 24hrs of onset of pain –
presence of fever at the beginning of attack
or rigor accompanies the onset of pain
excludes appendicitis
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Constipation
Tachycardia
Abdominal distension
Testicular symptoms
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Constant findings – epigastric pain, nausea
vomiting, RIF pain, low grade fever, local
tenderness
Local rigidity, fever, hyperesthesia and
constipation- inconstant
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Perforation with presence of mass or
generalized peritonitis usually does not
occur before 48 hrs.
After rupture the pain decreases and
localised pelvic peritonitis sets in but there
is no rigidity and patient seems to be
better.
Perforated pelvis appendix will cause
symptoms like diarrhoea, tenesmus,
frequency of micturition
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Intestinal obstruction a/c
Mesenteric vessel thrombosis
A/c pancreatitis
Peritonitis due to other causes
Pylephlebitis
Cholecystitis
DU perforation
Merkels diverticulitis
Perforated typhoid ulcer
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Uterine colic
Twisted/ rupture ovarian cyst
Ruptured ectopic
Twisted fibroid/ hydrosalpinx
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Diagnose early and treat promptly usually surgical
If treatment delayed for >24hrs outcome is poor
(<6hrs good)
Early stage- first 2hrs- symptoms are due to pain
consequent on flooding of peritoneal cavity with
gastric contents
Intermediate stage 2-12 hrs pain subsides patient
looks comfortable. Other clinical symptoms show
improvement but local signs remain. The most
opportune period for surgery and should never be
allowed to pass Most reliable signs are rigidity,
tenderness of pelvic peritoneum, shifting dullness,
free air and pain shoulder
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Late stage >12hrs increasing distension and
Hippocratic facies
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Failure to diagnose is due to failure to
consider its possibility
Symptoms variable- pain in the acute with the
patient crying out in agony, shock due to
hypovolemia, reflux vomiting and fever
invariable
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Epigastric tumour
Jaundice- Heads on CBD
Obstructive vomiting -heads on duodenum
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Ecchymosis, Cullen and Grey Turner indicate
severe disease and never occurs until 2-3
days
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Prodormal stage – episode of biliary colic
usually a forerunner
Vomiting, fever common and rarely jaundice
GB when palpable with compatible history,
establishes the diagnosis.
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Intestinal colic
Main feature of colic is occurrence of acute
agonizing spasmodic pain which causes the
patient to double up and partial or complete
relief in between.
Other features- vomiting, visible peristalsis,
borborygmi on auscultation
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Biliary colic
Misnomer because pain is steady
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Renal colic- due to renal stones
Characteristic pain from loin radiating to
groin, testes/vulva
Restlessness, vomiting, dysuria, increased
urinary frequency and hematuria
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Uterine colic (dysmenorrhoea)
Lower lumbar pain sometimes radiating to
thighs and hips
Congestive dysmenorrhoea pain increases
before the onset on menses and is relieved
with the onset of menstruation
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Causes- hernia (mc), adhesions,
intussusception, Ca, volvulus etc.
Symptoms according to site and cause of
obstruction
In general higher up the gut, more severe
the symptoms
Pain very severe referred to epigastrium,
umbilical or hypogastium
Clinically- distension, visible peristalsis,
features of shock
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Vomiting very early, frequent and violent,
green and bilious
Distension is not an early feature
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Pain is less severe than proximal small bowel
obstruction
Vomiting and distension delayed
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Distension is an early feature except in
intussusception
Pain less acute, shock and vomiting rare.
Can be due to strangulation of bowel where
tenderness on applying pressure is positive.
Obstruction can be due to volvulus, Ca colon,
impacted fecal matter etc
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Ectopic gestation
Retroverted gravid uterus
Threatened abortion
Sepsis following abortion
Torsion ovarian cyst/ fibroid
Red degeneration fibroid
Rupture uterus
Appendicitis
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Symptoms before rupture– ammenorrhoea,
localised hypogastric pain and tenderness,
uterine bleeding and sometimes tender
swelling in lateral fornix and passage of
membrane per vagina
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Symptoms of rupture – sudden abdominal
pain, vomiting, faintness, sudden anemia and
collapse with small, rapid pulse and
subnormal temp.
Signs – tender tumid, free fluid in abdominal
cavity, tenderness on pressing the finger
against pouch of Douglas
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Subacute presentation– repeated slight
hemorrhages with no history of a/c collapse
Presents with repeated attacks of pain,
faintness and uterine bleeding
Signs– lower abdominal tenderness, fullness
in one or both fornices, retention of urine.
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Symptoms– according to part and extent of
peritoneum involved, presence of infection
and acuteness of onset.
Reflex symptoms– pain, vomiting, rigidity.
Toxic symptoms– alteration in temperature,
collapse, distension, general toxemia.
Pain is the most common symptom.
Vomiting common at the onset but
infrequent until late.
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Amebiasis
Malaria
Worm infestation
Sickle cell anemia
Pyomyositis (in HIV)
Enteric fever
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Diabetic ketoacidosis
Typhoid
Malaria
TB peritonitis
Food poisoning
Lead colic
Porphyia
Pleurisy/pneumonia
Cardiac disease (eg. MI)
Disease of spine affecting nerve roots
Renal disease
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24 yo healthy M with one day hx of abdominal
pain. Pain was generalized at first, now worse in
right lower abd & radiates to his right groin. He has
vomited twice today. Denies any diarrhea, fevers,
dysuria or other complaints. No appetite today.
ROS otherwise negative.
PMHx: negative
PSurgHx: negative
Meds: none
NKDA
Social hx: no alcohol, tobacco or drug use
Family hx: non-contributory
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Physical exam:
T: 37.8, HR: 95, BP 118/76, R: 18, O2 sat:
100% room air
Uncomfortable appearing, slightly pale
Abdomen: soft, non-distended, tender to
palpation in RLQ with mild guarding;
hypoactive bowel sounds
Genital exam: normal
What is your differential diagnosis and what do
you do next?
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Classic presentation
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Periumbilical pain
Anorexia, nausea, vomiting
Pain localizes to RLQ
Occurs only in ½ to 2/3 of
patients
26% of appendices are
retrocecal and cause pain in
the flank; 4% are in the RUQ
A pelvic appendix can cause
suprapubic pain, dysuria
Males may have pain in the
testicles
Findings
◦ Depends on duration of
symptoms
◦ Rebound, voluntary guarding,
rigidity, tenderness on rectal
exam
◦ Psoas sign
◦ Obturator sign
◦ Fever (a late finding)
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Urinalysis abnormal in 19-40%
CBC is not sensitive or specific
Abdominal xrays
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CT scan
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◦ Appendiceal fecalith or gas,
localized ileus, blurred right
psoas muscle, free air
◦ Pericecal inflammation, abscess,
periappendiceal phlegmon, fluid
collection, localized fat
stranding
Passively flex
right hip and knee
then internally
rotate the hip
Cecum
Abscess, fat
stranding
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Diagnosis
◦ WBC
◦ Clinical appendicitis –
call your surgeon
◦ Maybe appendicitis - CT
scan
◦ Not likely appendicitis –
observe for 6-12 hours
or re-examination in 12
hours
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Treatment
◦ NPO
◦ IVFs
◦ Preoperative antibiotics
– decrease the incidence
of postoperative wound
infections
 Cover anaerobes, gramnegative and enterococci
 Zosyn 3.375 grams IV or
Unasyn 3 grams IV
◦ Analgesia
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68 yo F with 2 days of LLQ abd pain, diarrhea,
fevers/chills, nausea; vomited once at home.
PMHx: HTN, diverticulosis
PSurgHx: negative
Meds: HCTZ
NKDA
Social hx: no alcohol, tobacco or drug use
Family hx: non-contributory104
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T: 37.6, HR: 100, BP: 145/90, R: 19, O2sat:
99% room air
Gen: uncomfortable appearing, slightly pale
CV/Pulmonary: normal heart and lung
exam, no LE edema, normal pulses
Abd: soft, moderately TTP LLQ
Rectal: normal tone, guiac neg brown stool
What is your differential diagnosis & what
next?
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Risk factors
◦ Diverticula
◦ Increasing age
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Clinical features
◦ Steady, deep
discomfort in LLQ
◦ Change in bowel
habits
◦ Urinary symptoms
◦ Tenesmus
◦ Paralytic ileus
◦ SBO
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Physical Exam
◦ Low-grade fever
◦ Localized tenderness
◦ Rebound and
guarding
◦ Left-sided pain on
rectal exam
◦ Occult blood
◦ Peritoneal signs
 Suggest perforation or
abscess rupture
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Diagnosis
◦ CT scan (IV and oral
contrast)
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Pericolic fat stranding
Diverticula
Thickened bowel wall
Peridiverticular
abscess
◦ Leukocytosis present
in only 36% of patients
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Treatment
◦ Fluids
◦ Correct electrolyte
abnormalities
◦ NPO
◦ Abx: gentamicin AND
metronidazole OR
clindamycin OR
levaquin/flagyl
◦ For outpatients (nontoxic)
 liquid diet x 48 hours
 cipro and flagyl
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46 yo M with hx of alcohol abuse with 3 days
of severe upper abd pain, vomiting,
subjective fevers.
Med Hx: negative
Surg Hx: negative
Meds: none; Allergies: NKDA
Social hx: homeless, heavy alcohol use,
smokes 2ppd, no drug use
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Vital signs: T: 37.4, HR: 115, BP: 98/65, R: 22,
O2sat: 95% room air
General: ill-appearing, appears in pain
CV: tachycardic, normal heart sounds, pulses
normal
Lungs: clear
Abdomen: mildly distended, moderately TTP
epigastric, +voluntary guarding
Rectal: heme neg stool
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What is your differential diagnosis & what next?
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Risk Factors
◦ Alcohol
◦ Gallstones
◦ Drugs
 Amiodarone, antivirals,
diuretics, NSAIDs,
antibiotics, more…..
◦ Severe hyperlipidemia
◦ Idiopathic
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Clinical Features
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Epigastric pain
Constant, boring pain
Radiates to back
Severe
N/V
bloating
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Physical Findings
◦ Low-grade fevers
◦ Tachycardia, hypotension
◦ Respiratory symptoms
 Atelectasis
 Pleural effusion
◦ Peritonitis – a late finding
◦ Ileus
◦ Cullen sign*
 Bluish discoloration around
the umbilicus
◦ Grey Turner sign*
 Bluish discoloration of the
flanks
*Signs of hemorrhagic pancreatitis
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Diagnosis
◦ Lipase
 Elevated more than 2
times normal
 Sensitivity and specificity
>90%
◦ Amylase
 Nonspecific
 Don’t bother…
◦ RUQ US if etiology unknown
◦ CT scan
 Insensitive in early or mild
disease
 NOT necessary to
diagnose pancreatitis
 Useful to evaluate for
complications
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Treatment
◦ NPO
◦ IV fluid resuscitation
 Maintain urine output of
100 mL/hr
◦ NGT if severe, persistent
nausea
◦ No antibiotics unless severe
disease
 E coli, Klebsiella,
enterococci, staphylococci,
pseudomonas
 Imipenem or cipro with
metronidazole
◦ Mild disease, tolerating oral
fluids
 Discharge on liquid diet
 Follow up in 24-48 hours
◦ All others, admit
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72 yo M with hx of CAD on aspirin and
Plavix with several days of dull upper abd
pain and now with worsening pain “in entire
abdomen” today. Some relief with food until
today, now worse after eating lunch.
Med Hx: CAD, HTN, CHF
Surg Hx: appendectomy
Meds: Aspirin, Plavix, Metoprolol, Lasix
Social hx: smokes 1ppd, denies alcohol or
drug use, lives alone
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T: 99.1, HR: 70, BP: 90/45, R: 22, O2sat:
96% room air
General: elderly, thin male, ill-appearing
CV: normal
Lungs: clear
Abd: mildly distended and diffusely tender
to palpation, +rebound and guarding
Rectal: blood-streaked heme + brown stool
What is your differential diagnosis & what
next?
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Risk Factors
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H. pylori
NSAIDs
Smoking
Hereditary
Clinical Features
◦ Burning epigastric pain
◦ Sharp, dull, achy, or “empty” or
“hungry” feeling
◦ Relieved by milk, food, or
antacids
◦ Awakens the patient at night
◦ Nausea, retrosternal pain and
belching are NOT related to PUD
◦ Atypical presentations in the
elderly
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Physical Findings
◦ Epigastric tenderness
◦ Severe, generalized pain
may indicate perforation
with peritonitis
◦ Occult or gross blood
per rectum or NGT if
bleeding
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Diagnosis
◦ Rectal exam for occult blood
◦ CBC
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◦ Avoid tobacco, NSAIDs,
aspirin
◦ PPI or H2 blocker
 Anemia from chronic blood
loss
◦ LFTs
 Evaluate for GB, liver and
pancreatic disease
◦ Definitive diagnosis is by
EGD or upper GI barium
study
Treatment
Empiric treatment
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Immediate referral to GI if:
>45 years
Weight loss
Long h/o symptoms
Anemia
Persistent anorexia or
vomiting
◦ Early satiety
◦ GIB
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Abrupt onset of severe epigastric pain
followed by peritonitis
IV, oxygen, monitor
CBC, T&C, Lipase
Acute abdominal x-ray series
◦ Lack of free air does NOT rule out perforation
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Broad-spectrum antibiotics
Surgical consultation
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35 yo healthy F to ED c/o nausea and vomiting
since yesterday along with generalized
abdominal pain. No fevers/chills, +anorexia.
Last stool 2 days ago.
Med Hx: negative
Surg Hx: s/p hysterectomy (for fibroids)
Meds: none, Allergies: NKDA
Social Hx: denies alcohol, tobacco or drug use
Family Hx: non-contributory
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T: 36.9, HR: 100, BP: 130/85, R: 22, O2 sat:
97% room air
General: mildly obese female, vomiting
CV: normal
Lungs: clear
Abd: moderately distended, mild TTP
diffusely, hypoactive bowel sounds, no
rebound or guarding
What is your differential and what next?
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Mechanical or
nonmechanical causes
◦ #1 - Adhesions from
previous surgery
◦ #2 - Groin hernia
incarceration
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Clinical Features
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Crampy, intermittent pain
Periumbilical or diffuse
Inability to have BM or flatus
N/V
Abdominal bloating
Sensation of fullness,
anorexia
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Physical Findings
◦ Distention
◦ Tympany
◦ Absent, high pitched or
tinkling bowel sound or
“rushes”
◦ Abdominal tenderness:
diffuse, localized, or
minimal
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Diagnosis
CBC and electrolytes
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Abdominal x-ray series
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◦ electrolyte abnormalities
◦ WBC >20,000 suggests
bowel necrosis, abscess or
peritonitis
◦ Flat, upright, and chest xray
◦ Air-fluid levels, dilated
loops of bowel
◦ Lack of gas in distal bowel
and rectum
CT scan
◦ Identify cause of obstruction
◦ Delineate partial from
complete obstruction
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Treatment
Fluid resuscitation
NGT
Analgesia
Surgical consult
Hospital observation for
ileus
◦ OR for complete obstruction
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 Peri-operative antibiotics
 Zosyn or unasyn
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48 yo obese F with one day hx of upper abd
pain after eating, does not radiate, is
intermittent cramping pain, +N/V, no
diarrhea, subjective fevers. No prior similar
symptoms.
Med hx: denies
Surg hx: denies
No meds or allergies
Social hx: no alcohol, tobacco or drug use
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T: 100.4, HR: 96, BP: 135/76, R: 18, O2 sat:
100% room air
General: moderately obese, no acute
distress
CV: normal
Lungs: clear
Abd: moderately TTP RUQ, +Murphy’s sign,
non-distended, normal bowel sounds
What is your differential and what next?
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Clinical Features
◦ RUQ or epigastric pain
◦ Radiation to the back
or shoulders
◦ Dull and achy → sharp
and localized
◦ Pain lasting longer
than 6 hours
◦ N/V/anorexia
◦ Fever, chills
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Physical Findings
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Epigastric or RUQ pain
Murphy’s sign
Patient appears ill
Peritoneal signs
suggest perforation
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Diagnosis
◦ CBC, LFTs, Lipase
 Elevated alkaline
phosphatase
 Elevated lipase suggests
gallstone pancreatitis
◦ RUQ US
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Thicken gallbladder wall
Pericholecystic fluid
Gallstones or sludge
Sonographic murphy sign
◦ HIDA scan
 more sensitive & specific
than US
◦ H&P and laboratory findings
have a poor predictive value
– if you suspect it, get the
US
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Treatment
◦ Surgical consult
◦ IV fluids
◦ Correct electrolyte
abnormalities
◦ Analgesia
◦ Antibiotics
 Ceftriaxone 1 gram IV
 If septic, broaden coverage
to zosyn, unasyn,
imipenem or add anaerobic
coverage to ceftriaxone
◦ NGT if intractable vomiting
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34 yo healthy M with 4 hour hx of sudden
onset left flank pain, +nausea/vomiting; no
prior hx of similar symptoms; no
fevers/chills. +difficulty urinating, no
hematuria. Feels like has to urinate but
cannot.
PMHx: neg
Surg Hx: neg
Meds: none, Allergies: NKDA
Social hx: occasional alcohol, denies
tobacco or drug use
Family hx: non-contributory
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T: 98.9, HR: 110, BP: 150/90, R: 20, O2 sat: 99%
room air
General: writhing around on stretcher in pain,
+diaphoretic
CV: tachycardic, heart sounds normal
Lungs: clear
Abd: soft; non-tender
Back: mild left CVA tenderness
Genital exam: normal
Neuro exam: normal
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What is your differential diagnosis and what next?
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Clinical Features
◦ Acute onset of severe,
dull, achy visceral pain
◦ Flank pain
◦ Radiates to abdomen
or groin including
testicles
◦ N/V and sometimes
diaphoresis
◦ Fever is unusual
◦ Waxing and waning
symptoms
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Physical Findings
◦ non tender or mild
tenderness to
palpation
◦ Anxious, pacing,
writhing in bed –
unable to sit still
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Diagnosis
◦ Urinalysis
 RBCs
 WBCs suggest infection or
other etiology for pain (ie
appendicitis)
◦ CBC
 If infection suspected
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Treatment
◦ IV fluid boluses
◦ Analgesia
 Narcotics
 NSAIDS
 If no renal insufficiency
◦ Strain all urine
◦ Follow up with urology in 12 weeks
◦ BUN/Creatinine
 In older patients
 If patient has single kidney
 If severe obstruction is
suspected
◦ CT scan
 In older patients or patients
with comorbidities (DM,
SCD)
 Not necessary in young
patients or patients with
h/o stones that pass
spontaneously
◦ If stone > 5mm, consider
admission and urology
consult
◦ If toxic appearing or
infection found
 IV antibiotics
 Urologic consult
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Ovarian torsion
Testicular torsion
GI bleeding
Abd pain in the Elderly
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Acute onset severe pelvic
pain
May wax and wane
Possible hx of ovarian cysts
Menstrual cycle: midcycle
also possibly in pregnancy
Can have variable exam:
◦ acute, rigid abdomen,
peritonitis
◦ Fever
◦ Tachycardia
◦ Decreased bowel sounds
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May look just like
Appendicitis
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Obtain ultrasound
Labs
◦ CBC, beta-hCG,
electrolytes, T&S
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IV fluids
NPO
Pain medications
GYN consult
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Sudden onset of severe
testicular pain
If torsion is repaired within 6
hours of the initial insult,
salvage rates of 80-100% are
typical. These rates decline
to nearly 0% at 24 hours.
Approximately 5-10% of
torsed testes spontaneously
detorse, but the risk of
retorsion at a later date
remains high.
Most occur in males less than
20yrs old but 10% of affected
patients are older than 30
years.
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Detorsion
Emergent urology
consult
Ultrasound with
doppler
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Mortality rate for
abdominal pain in the
elderly is 11-14%
Perception of pain is
altered
Altered reporting of
pain: stoicism, fear,
communication
problems
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Most common causes:
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Cholecystitis
Appendicitis
Bowel obstruction
Diverticulitis
Perforated peptic ulcer
Don’t miss these:
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AAA, ruptured AAA
Mesenteric ischemia
Myocardial ischemia
Aortic dissection
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Appendicitis – do not exclude it because of
prolonged symptoms. Only 20% will have fever,
N/V, RLQ pain and ↑WBC
Acute cholecystitis – most common surgical
emergency in the elderly.
Perforated peptic ulcer – only 50% report a sudden
onset of pain. In one series, missed diagnosis of
PPU was leading cause of death.
Mesenteric ischemia – we make the diagnosis only
25% of the time. Early diagnosis improves chances
of survival. Overall survival is 30%.
Increased frequency of abdominal aortic aneurysms
AAA may look like renal colic in elderly patients
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Consider this diagnosis in all elderly patients with risk factors
◦ Atrial fibrillation, recent MI
◦ Atherosclerosis, CHF, digoxin therapy
◦ Hypercoagulability, prior DVT, liver disease
Severe pain, often refractory to analgesics
Relatively normal abdominal exam
Embolic source: sudden onset (more gradual if thrombosis)
Nausea, vomiting and anorexia are common
50% will have diarrhea
Eventually stools will be guiaic-positive
Metabolic acidosis and extreme leukocytosis when advanced
disease is present (bowel necrosis)
Diagnosis requires mesenteric angiography or CT
angiography
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Risk increases with age, women >70, men >55
Abdominal pain in 70-80% (not back pain!)
Back pain in 50%
Sudden onset of significant pain
Atypical locations of pain: hips, inguinal area, external genitalia
Syncope can occur
Hypotension may be present
Palpation of a tender, enlarged aorta on exam is an important
finding
May present with hematuria
Suspect it in any older patient with back, flank or abdominal pain
especially with a renal colic presentation
Ultrasound can reveal the presence of a AAA but is not helpful for
rupture. CT abd/pelvis without contrast for stable patients. High
suspicion in an unstable patient requires surgical consult and
emergent surgery.
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Upper
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Proximal to Ligament of Treitz
Peptic ulcer disease most common
Erosive gastritis
Esophagitis
Esophageal and gastric varices
Mallory-Weiss tear
Lower
◦ Hemorrhoids most common
◦ Diverticulosis
◦ Angiodysplasia
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Common Presentation:
Hematemesis (source proximal to right colon)
Coffee-ground emesis
Melena
Hematochezia (distal colorectal source)
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High level of suspicion with
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Hypotension
Tachycardia
Angina
Syncope
Weakness
Confusion
Cardiac arrest
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Type and crossmatch: Most important!
Other studies: CBC, BUN, creatinine, electrolyte, coagulation
studies, LFTs
Initial Hct often will not reflect the actual amount
of blood loss
Abdominal and chest x-rays of limited value for
source of bleed
Nasogastric (NG) tube
◦ Gastric lavage
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Angiography
Bleeding scan
Endoscopy/colonoscopy
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ABCs of Resuscitation
AIRWAY:
◦ Consider definitive airway to prevent aspiration of
blood
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BREATHING
◦ Supplemental Oxygen
◦ Continuous pulse oximetry
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Circulation
◦ Cardiac monitoring
◦ Volume replacement
 Crystalloids
 2 large-bore intravenous lines (18g or larger)
◦ Blood Products
 General guidelines for transfusion
 Active bleeding
 Failure to improve perfusion and vital signs after the infusion
of 2 L of crystalloid
 Lower threshold in the elderly
 NOT BASED ON INITIAL HEMATOCRIT ALONE
◦ Coagulation factors replaced as needed
◦ Urinary catheter with hypotension to monitor
output
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Early GI consult for severe bleeds
Therapeutic Endoscopy: band ligation or
injection sclerotherapy
◦ Also….electrocoagulation, heater probes, and lasers
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Drug Therapy: somatostatin, octreotide,
vasopressin, PPIs
Balloon tamponade: adjunct or
temporizing measure
Surgery: if all else fails
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ADMIT
◦ Certain patients with lower GI bleeding may be discharged
for Outpatient work-up
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Patients are risk stratified by clinical and
endoscopic criteria
Independent predictors of adverse outcomes in
upper GI bleeding (Corley and colleagues):
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Initial hematocrit < 30 %
Initial SBP < 100 mm Hg
Red blood in the NG lavage
History of cirrhosis or ascites on examination
History of vomiting red blood
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Significant abdominal tenderness should never be attributed to
gastroenteritis
Incidence of gastroenteritis in the elderly is very low
Always perform genital examinations when lower abdominal pain is
present – in males and females, in young and old
In older patients with renal colic symptoms, exclude AAA
Severe pain should be taken as an indicator of serious disease
Pain awakening the patient from sleep should always be considered
signficant
Sudden, severe pain suggests serious disease
Pain almost always precedes vomiting in surgical causes; converse is
true for most gastroenteritis and NSAP
Acute cholecystitis is the most common surgical emergency in the
elderly
A lack of free air on a chest xray does NOT rule out perforation
Signs and symptoms of PUD, gastritis, reflux and nonspecific
dyspepsia have significant overlap
If the pain of biliary colic lasts more than 6 hours, suspect early
cholecystitis